Guidelines & Protocols Advisory Committee

Thyroid Function Testing in the Diagnosis and

Monitoring of Thyroid Function Disorder
Effective Date: October 24, 2018

Scope
This guideline outlines testing for thyroid dysfunction in patients (pediatric and adult), including pregnant women or women
planning pregnancy, and the monitoring of patients treated for primary thyroid function disorders. It does not apply to the BC
Newborn Screening Program. This guideline outlines testing for thyroid stimulating hormone (TSH), free thyroxine (fT4), free
triiodothyronine (fT3) and anti-thyroid peroxidase (TPO).

Information on other tests, including thyroglobulin/antithyroglobulin (Tg/anti Tg) and antibodies to the thyroid stimulating
hormone receptor (TRAb), are covered in the associated BC Guideline Hormone Testing – Indications and Appropriate Use.

Key Recommendations
• Routine thyroid function testing is not recommended in asymptomatic patients (outside of the BC Newborn Screening
Program). Testing may be indicated when non-specific symptoms or signs are present in patients at risk for thyroid disease.
• A TSH value within the laboratory reference interval excludes the majority of cases of primary thyroid dysfunction.
• If initial TSH testing is normal, repeat testing is unnecessary unless there is a change in clinical condition.
• Measurement of fT3 is rarely indicated in suspected thyroid disease.
• Screening for undiagnosed hyperthyroidism or hypothyroidism should not be performed in hospitalized patients
or during acute illness unless hyperthyroidism or hypothyroidism is the suspected cause of the clinical presentation or
represents a significant co-morbidity.
• If a woman is pregnant or planning pregnancy, TSH testing is indicated if she has specific risk factors (see Table 3).

Indications for Testing

Routine thyroid function testing is not recommended in asymptomatic patients (outside of the BC Newborn Screening
Program). Testing may be indicated when non-specific symptoms or signs are present in patients who have specific risk factors
for thyroid disease. Testing is indicated for patients with a clinical presentation consistent with thyroid disease as delineated in
Table 1: Symptoms and Signs of Thyroid Disease below.
Where thyroid testing in an asymptomatic patient has occurred and the patient has been diagnosed with subclinical thyroid
disease, see the Subclinical Thyroid Disease section.
If initial testing is normal, repeat testing is unnecessary unless there is a change in clinical condition.

Risk Factors
Risk factors for thyroid disease include: 1
• men: age ≥ 60 years; 2
• women: age ≥ 50 years; 2
• personal history or strong family history of thyroid disease;
 • diagnosis of other autoimmune diseases;
• past history of neck irradiation;
• previous thyroidectomy or radioactive iodine ablation;
• drug therapies such as lithium and amiodarone;
• dietary factors (iodine excess and iodine deficiency in patients from developing countries); or
• certain chromosomal or genetic disorders (e.g., Turner syndrome,3 Down syndrome 4 and mitochondrial disease 5).

For risk factors during pregnancy, see Table 3 in the Thyroid Disease in Pregnancy section below.

Signs and Symptoms

Table 1: Symptoms and Signs of Thyroid Disease1, 6, 7
This table reflects common manifestations of thyroid disease in adults. Pediatric-specific manifestations of hypothyroidism (e.g.,
slow growth and delayed osseous maturation,8 delayed puberty or precocious puberty (in severe longstanding hypothyroidism) 9)
or hyperthyroidism (e.g., difficulty gaining weight, growth acceleration, advanced bone age or delayed puberty 9) should also be
considered in the pediatric context.

Hypothyroidism: Symptoms and Signs Hyperthyroidism: Symptoms and Signs

• Depression • Anxiety, irritability, restlessness
• Decreased mental function • Fatigue, restless sleep
Neuropsychiatric • Increased appetite
• Decreased attention span

• Physical tiredness • Tremors

• Paresthesia • Proximal muscle weakness
Neuromuscular • Hypokinesis • Hyperreflexia
• Hyporeflexia

• Weight gain A • Weight loss

Physical Appearance/ • Coarse, dry skin • Hair loss
Voice • Periorbital edema
• Hoarseness

• Bradycardia • Palpitations, tachycardia

Cardiovascular • Isolated diastolic hypertension • Atrial fibrillation
• Isolated systolic hypertension

Thyroid Gland • Goitre • Goitre

• Diminished sweating • Increased sweating

Thermoregulation • Cold intolerance • Heat intolerance

• Blurred or double vision

Ophthalmologic • Dry eyes, conjunctivitis, proptosis or dysconjugate gaze

Gastrointestinal • Constipation • Increased frequency of stools

Pituitary Function • Menorrhagia • Amenorrhea/oligomenorrhea

A. Hypothyroidism rarely causes weight gain in pediatric populations.9

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Tests
Thyroid Stimulating Hormone (TSH)
Measurement of TSH is the principal test for the evaluation of thyroid function in the vast majority of circumstances10 provided
there is no clinical or historical evidence to suggest damage or disease of the hypothalamic-pituitary axis. Hypothalamic
and pituitary disease can cause central hypothyroidism, which is rare.11, 12 Central hypothyroidism can be caused by invasive
or compressive lesions, iatrogenic factors, injuries, vascular accidents, autoimmune disease, infiltrative disease, congenital
conditions and infections.11 If central hypothyroidism is being investigated “suspicion of pituitary insufficiency” should be
included as a clinical indication and a request for fT4 (with or without TSH) should be indicated in the space provided on
the standard out-patient laboratory requisition (see Appendix 1: BC Laboratory Algorithm for Thyroid Tests).
A TSH value within the laboratory reference interval excludes the majority of cases of primary thyroid dysfunction.6 The
TSH reference interval will vary depending on the testing laboratory. Laboratories in BC retain specimens for 2 to 7 days in case
add-on testing is required (see Appendix 1: BC Laboratory Algorithm for Thyroid Tests).
• If “suspected hyperthyroidism” is chosen on the standard out-patient laboratory requisition, the laboratory will perform
the TSH test first and then automatically perform the fT4 and fT3 if required.
• If “suspected hypothyroidism” is chosen on the standard out-patient laboratory requisition, the laboratory will perform
the TSH test first and then automatically perform the fT4 if required.
• If free thyroid hormones are ordered without TSH, a clinical indication is required.
See Figure 1 for a Clinical Algorithm of Thyroid Function Tests for Diagnosis and Monitoring in Symptomatic Non-Pregnant
Patients and Table 2 for Potential Causes of Abnormal Hormone Levels.

Free Thyroxine (fT4) and Free Triiodothyronine (fT3)

Measurements of fT4 and fT3 have replaced those of total T4 and total T3 levels. Laboratories are permitted to substitute free
hormone assays when total T3 or T4 have been ordered.
Measurement of fT3 is rarely indicated in suspected thyroid disease.6, 13 This is reserved for situations where thyroid
disease is suspected clinically and TSH is abnormal, but fT4 is inappropriately normal.

Anti-Thyroid Peroxidase (TPO)

Anti-TPO measurement is not routinely indicated in patients with hypothyroidism as it does not generally change clinical
management. In specific circumstances it may be helpful in further clinical decision making. In patients with a goitre or
mildly elevated TSH, anti-TPO measurement is used to evaluate whether the cause is autoimmune thyroiditis.13 TPO antibody
positivity increases the risk of developing hypothyroidism in patients with subclinical hypothyroidism, autoimmune diseases
(e.g., type 1 diabetes), chromosomal disorders (e.g., Turner syndrome and Down syndrome) or patients who are on certain drug
therapies (e.g., lithium, amiodarone) or are pregnant or postpartum (see Thyroid Disease in Pregnancy section below).13, 14 Once
a patient is known to be TPO antibody positive, repeat analysis is not indicated.

There are other thyroid antibody tests with specific indications which are not covered in this guideline and are
discussed in the associated BC Guideline Hormone Testing – Indications and Appropriate Use.

Follow-Up Testing
In most cases, ordering a different test is more useful than repeating the same test (e.g., if a patient has specific clinical findings
and a TSH result does not appear to correlate with the patient’s clinical status, it may be more appropriate to follow with an
fT4 measurement). If fT4 is being ordered to investigate or follow central hypothyroidism, “suspicion of pituitary insufficiency”
should be included as a clinical indication and a request for fT4 (with or without TSH) should be written in the space provided
on the standard out-patient laboratory requisition.

Consultation with a lab physician or an endocrinologist is recommended when the test result is in conflict with the
clinical presentation so that investigation for analytical interferences or rare conditions can be undertaken.

Note that thyroid ultrasound scan is not routinely recommended in patients with abnormal thyroid function tests, unless there
is a palpable abnormality of the thyroid gland (Choosing Wisely Endocrinology and Metabolism Recommendation). See the
associated BC Guideline Ultrasound Prioritization.

3 [Link]: Thyroid Function Testing in the Diagnosis and Monitoring of Thyroid Function Disorder (2018)
 Figure 1: Clinical Algorithm for Thyroid Function Tests for Diagnosis and Monitoring in Symptomatic
Non-Pregnant Patients.

This algorithm only applies to patients with an intact hypothalamic-pituitary axis and does not apply to hospitalized patients
(Sick Euthyroid Syndrome). For information during pregnancy, see the Thyroid Disease in Pregnancy section. For laboratory testing
procedures, see Appendix 1: BC Laboratory Algorithm for Thyroid Tests.

Hyperthyroidism suspected Normal TSH levels Hypothyroidism suspected

TSH test: (Check “hyperthyroidism suspected” TSH within reference rangeA (Check “hypothyroidism suspected”
on the standard out-patient on the standard out-patient
ordered by
laboratory requisition) TSH below laboratory requisition) TSH above
practitioner
the lower limit of normalA Review clinial dianosis the upper limit of normalA
fT4 + fT3 tests not indicated

fT4 test:
fT4 fT4
automatically
performed by
lab if TSH
abnormal Normal High Low NormalB

fT3 test:
automatically fT3
performed by
lab if TSH
low and Normal High
fT4 normal

See Table 2 for other Hyperthyroidism Hypothyroidism See Table 2 for other
diagnostic considerationsC confirmed (see Table 2) confirmed (see Table 2) diagnostic considerationsC
Repeat TSH at 6 –12 months Seek specialist consult Repeat TSH at 6 –12 months
or sooner if the clinical if patient is pregnant or or sooner if the clinical
situation changes planning pregnancy situation changes

Monitor TSH
Wait 6 weeks after start of treatment or
change in dosage before re-testing TSH

Notes:
A. TSH reference intervals may vary depending on the testing lab.
B. Overt primary hypothyroidism is diagnosed when the TSH is elevated and the fT4 is low. A decision to treat is often made
if the TSH is >10 mU/L even if the fT4 is within the reference range.
C. An abnormal TSH level, associated with a normal fT4 and fT3 level is most often due to subclinical thyroid dysfunction.
Rarely, it may be related to a lab artefact such as antibody interference.

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 Table 2. Potential Causes of Abnormal Hormone Levels (TSH, fT4 and fT3)
Causes of High TSH15–17 Laboratory Result Follow-up
Hypothyroidism TSH Ÿ, fT4 6
See Monitoring: Hypothyroidism or
• Autoimmune Thyroid Disease in Pregnancy
Subclinical hypothyroidism TSH Ÿ (usually less than 10 mU/L),A See Subclinical Hypothyroidism or
• Typically asymptomatic fT4 normal 13, 18 Thyroid Disease in Pregnancy
• Assay artefact B (fT3 not indicated)
Recovery from non-thyroidal illness Testing not usually indicated See Sick Euthyroid Syndrome
• Sick Euthyroid Syndrome As patients recover, TSH may
normalize or become elevated 19
Very rare causes TSH Ÿ (or normal), fT4 Ÿ 15, 16 See Monitoring: Hypothalamic or
• Pituitary disease Consult with a specialist (lab physician, Pituitary Disease
• Resistance to thyroid hormone internist or endocrinologist)
• Assay artefact B
Causes of Low TSH15–17 Laboratory Result Follow-up
Hyperthyroidism or other causes of TSH , fT4 Ÿ 6 See Monitoring: Hyperthyroidism
thyrotoxicosis (fT3 not indicated)  See Thyroid Disease in Pregnancy
• Excessive thyroid hormone replacement
(levothyroxine)
• Graves’ disease
• Subacute thyroiditis (viral)
• Painless/postpartum thyroiditis
(autoimmune)
• Toxic (multinodular) goitre
Hyperthyroidism or other causes TSH , fT4 normal/low, fT3 Ÿ 6 See Monitoring: Hyperthyroidism
of thyrotoxicosis See Thyroid Disease in Pregnancy
• T3 thyrotoxicosis (e.g., autonomous
nodule)
• Excessive thyroid hormone replacement
(liothyronine or desiccated thyroid)
Subclinical hyperthyroidism TSH A
, fT4 normal, fT3 normal 21 See Subclinical Hyperthyroidism
• Recovery of hyperthyroidism See Thyroid Disease in Pregnancy
• Pregnancy related 14, 20
• Assay artefactB
Sick Euthyroid Syndrome Testing not usually indicated See Sick Euthyroid Syndrome
• Hospitalized patients, Any abnormality in levels is possible
recovery from severe illness • Usually: TSH or normal, fT4 or
normal, fT3 12, 16
• As patients recover, TSH may
normalize or become elevated 19
Very rare causes TSH normal (or ), fT4 6 See Monitoring: Hypothalamic or
• Central hypothyroidism (hypopituitarism) Consult with a specialist (lab physician, Pituitary Disease
• Assay artefact B internist or endocrinologist)
A. Treatment is considered when TSH is above 10 mU/L18 for subclinical hypothyroidism or below 0.1 mU/L21 for subclinical
hyperthyroidism.
B. Assay artefact may cause abnormal laboratory results. Immunoassays for thyroid function tests are subject to analytical
interference due to heterophile antibodies,22 variant TSH isoforms by glycosylation,22 macro TSH (TSH in combination with
IgG antibody),22 or high dose biotin administration.23 If an assay artefact is suspected, consult with a lab physician.

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Monitoring of Thyroid Disease
Hypothyroidism
Since TSH values change slowly,24 frequent repeat testing is not indicated. TSH may be repeated after at least 6 weeks following
a change in thyroid hormone replacement dose or in a patient’s clinical status.13 Care should be taken not to overtreat with
levothyroxine, as it can result in atrial fibrillation (more commonly in the elderly) and bone loss in postmenopausal women.13

Once TSH has normalized with treatment, it should be checked annually unless a new indication arises. This confirms adequacy
of treatment dose and compliance with therapy.

Note that even within the reference interval, TSH levels in the same individual can vary by 50% when measured at different
times of day, with lowest values in the late afternoon and highest values at midnight.25 In individuals with subclinical
hypothyroidism, TSH values can vary by up to 40% even when measured at the same time on different days without indicating
a change in thyroid function.26 As long as TSH remains within the reference interval, changes over time are not important.

Patients taking lithium and amiodarone are at increased risk for hypothyroidism13 and monitoring of TSH is recommended
every 6 months. Amiodarone treatment may also lead to amiodarone-induced thyrotoxicosis and monitoring is recommended
every 3-6 months.21

Hyperthyroidism
To monitor patients on treatment for Graves’ disease or other causes of hyperthyroidism, allow at least one month or longer
before repeating fT4 and TSH levels since pituitary secretion of TSH may be suppressed for protracted periods following
hyperthyroidism.21 Until TSH suppression resolves, initial treatment and dosing decisions should be based on fT4, or in the
case of T3 thyrotoxicosis, on fT3.21

Patients taking amiodarone are at increased risk of amiodarone-induced thyrotoxicosis and monitoring is recommended every
3–6 months.21

Hypothalamic or Pituitary Disease

TSH is only useful as a measure of thyroid disease if the hypothalamic-pituitary-thyroid axis is intact. When pituitary or
hypothalamic disease is suspected, fT4 measurement is required to make the diagnosis or assess adequacy of thyroid
replacement therapy.11, 12

Subclinical Thyroid Disease

Subclinical thyroid disease is a biochemical diagnosis and typically has either no symptoms or non-specific symptoms, is more
common in women, and prevalence increases with advanced age.18, 21

Subclinical Hypothyroidism
In subclinical hypothyroidism, TSH is elevated in the presence of normal levels of fT4 (see Table 2).13, 18

Treatment for subclinical hypothyroidism is recommended when TSH rises above 10 mU/L.18 Treatment can be
considered when TSH is between the upper limit of the reference interval but ≤10 mU/L and any of the following are present:13
• symptoms suggestive of hypothyroidism;
• elevated TPO antibodies;
• evidence of atherosclerotic cardiovascular disease, heart failure, or associated risk factors for these diseases; or
• pregnancy (see Thyroid Disease in Pregnancy section below).

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 The prevalence of subclinical hypothyroidism in the general population is between 4.3–8.5%.13 Every year, 2.6% of subclinical
hypothyroidism patients without elevated TPO antibodies and 4.3% of subclinical hypothyroidism patients with elevated TPO
antibodies progress to overt hypothyroidism.13

Monitoring of TSH in untreated patients with subclinical hypothyroidism is indicated at 6–12 month intervals, or
sooner if the clinical situation changes.27

Subclinical Hyperthyroidism
In subclinical hyperthyroidism, the TSH is suppressed in the presence of normal levels of fT4 (see Table 2).21 Subclinical
hyperthyroidism is less common, with a prevalence of 0.7%.21

Patients with atrial fibrillation or osteoporosis should be screened for hyperthyroidism. In patients over age 60 with TSH
< 0.1 mU/L but with a normal fT4, the relative risk for atrial fibrillation increases threefold.28 Post-menopausal women with
subclinical hyperthyroidism may have an increased rate of bone loss.29 In the elderly, there is a higher cardiovascular risk and an
increased risk of fracture. Treatment of subclinical hyperthyroidism should be considered in the elderly.21, 30 Patients with
subclinical hyperthyroidism due to multi-nodular goitre or toxic adenoma are unlikely to normalize and are therefore more
likely to benefit from treatment.

Sick Euthyroid Syndrome

In Sick Euthyroid Syndrome (Non-Thyroidal Illness Syndrome), the hypothalamic-pituitary-thyroid axis is affected by a non-thyroid
illness. It occurs in patients without a previously diagnosed thyroid disease.31

Almost any condition that can make a person ill can cause Sick Euthyroid Syndrome and the elderly are more susceptible
because of multiple co-morbid conditions.15 The syndrome is acute and spontaneously reverses and occurs commonly after
surgery, during fasting, during many acute febrile illnesses, and after acute myocardial infarction. Malnutrition, renal and cardiac
failure, hepatic diseases, uncontrolled diabetes, cerebrovascular diseases, and malignancy can also produce abnormalities in
thyroid function tests.15

Testing
Ideally, thyroid function tests should not be performed in hospitalized patients unless hyperthyroidism or
hypothyroidism is the suspected cause of the clinical presentation or represents a significant co-morbidity. However, where
thyroid testing has occurred, any abnormal results should be interpreted with caution and with a realization that Sick Euthyroid
Syndrome is the most likely explanation for the finding if performed in hospitalized patients rather than true thyroid disease.

Multiple patterns of hormone levels are possible (see Table 2); abnormalities fluctuate during the course of illness and recovery.
However, usually fT3 is low, fT4 is low in some sicker patients, and TSH is low or normal.12,16 As patients recover from their illness,
TSH may normalize or become elevated.19

TSH levels must be interpreted with caution in hospitalized individuals. However, values below < 0.1 mU/L or > 20 mU/L merit
a consultation with endocrinology or internal medicine.10 Levothyroxine replacement has not been shown to be beneficial and
should not be used in patients with Sick Euthyroid Syndrome.12

Thyroid Disease in Pregnancy

Currently, there is insufficient evidence to advocate for universal screening (see Universal Screening During Pregnancy in the
Controversies in Care Section below). Based on the 2017 Guidelines of the American Thyroid Association for the Diagnosis and
Management of Thyroid Disease During Pregnancy and the Postpartum, if a woman is pregnant or planning pregnancy, TSH testing
is indicated if she has any of the risk factors listed in Table 3.14 Pregnant women often experience symptoms that can be non-
specific or vague and as such, it may be difficult to distinguish between symptoms of thyroid dysfunction and normal changes
of pregnancy. Clinicians should have a low threshold for TSH testing in pregnancy.

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 Table 3. Risk Factors for Thyroid Disease in Women who are Pregnant or Anticipating Becoming Pregnant14
• age > 30 years
• more than 2 prior pregnancies
• history of pregnancy loss, preterm delivery, or infertility
• type 1 diabetes or other autoimmune disorders
• morbid obesity (BMI ≥ 40 kg/m2)
• history of hypothyroidism/hyperthyroidism or current symptoms or signs of thyroid dysfunction
• family history of autoimmune thyroid disease or thyroid dysfunction (1st degree relative 32)
• history of head or neck radiation or prior thyroid surgery
• known TPO antibody positivity or presence of a goitre
• currently receiving levothyroxine replacement 33
• use of amiodarone or lithium, or recent administration of iodinated radiologic contrast
• residing (or recently resided) in an area of known moderate to severe iodine insufficiency

Hypothyroidism in Pregnancy and Postpartum

Research data support a possible connection between untreated overt maternal hypothyroidism and neuropsychological
impairment in the offspring.34, 35 If hypothyroidism has been diagnosed before or during pregnancy, treatment should be
adjusted to achieve a TSH level within the normal trimester specific reference interval.

First trimester reference intervals, in particular, are less than the normal population reference interval. Laboratories in BC should
report trimester specific reference intervals as an appended comment on all women of child bearing age. Treatment should
be initiated for women whose TSH is above the trimester specific upper limit of normal as reported by the laboratory (see
Treatment of Women with Subclinical Hypothyroidism in the Controversies in Care Section below).

A preconception TSH between the lower reference limit and 2.5 mU/L is recommended in women being actively treated for
hypothyroidism.14

In women with overt and subclinical hypothyroidism (treated or untreated) and women at risk for hypothyroidism (euthyroid
patients who are TPO antibody positive, post-hemithyroidectomy or treated with radioactive iodine), TSH should be measured
every 4–6 weeks until midgestation and at least once near 30 weeks gestation.14

In women being treated for hypothyroidism, levothyroxine replacement dosage may need to increase by 25–50% during
pregnancy, particularly in the first trimester.20, 33 After starting thyroid hormone replacement or a dose change during
pregnancy, TSH should be remeasured every 4–6 weeks.20, 33

Postpartum
After delivery, most women treated for hypothyroidism will need a decrease in the levothyroxine dose that they received
during pregnancy. TSH should be evaluated 6 weeks after the dose change.14

Hyperthyroidism in Pregnancy and Postpartum

Hyperthyroid patients should have appropriate specialist consultation (endocrinologist or maternal-fetal medicine
(e.g., obstetric internal medicine)) when contemplating pregnancy or during pregnancy.

In the course of a normal pregnancy, TSH may be low in the first trimester, when human chorionic gonadotropin (hCG) peaks.
Pathological causes of low TSH in pregnancy may include multiple gestation, hyperemesis gravidarum and molar pregnancy.14
In this context, a normal fT4 generally excludes hyperthyroidism.14, 20 After hCG mediated hyperthyroidism, the most common
pathological cause of hyperthyroidism in pregnancy is autoimmune Grave’s disease. Toxic multinodular goitre and toxic
adenoma are less common than autoimmune causes.14

During pregnancy, if TSH is low, repeat the TSH along with fT414 (using laboratory reported pregnancy specific reference
intervals). If TSH is still low and fT4 is high, refer to a specialist in endocrinology or maternal-fetal medicine (e.g., obstetric
internal medicine). If TSH is still low but fT4 is normal, repeat testing in 4 weeks is suggested. If TSH is still low referral to a
specialist is recommended.

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 Postpartum
Because of changes in the modulation of the immune system, there is an increased risk of thyroiditis and new presentation or
relapse of Graves’ disease in the postpartum period.14 One study found that hyperthyroidism diagnosed within 3 months of
delivery was most often caused by postpartum thyroiditis while hyperthyroidism diagnosed after 6.5 months was caused by
Graves’ disease.36

If a patient is persistently hyperthyroid postpartum, referral to an appropriate specialist in endocrinology or maternal-

fetal medicine (e.g., obstetric internal medicine) is recommended.

Postpartum Thyroiditis
Postpartum thyroiditis is an autoimmune disorder and the presence of anti-TPO antibodies increases the risk of disease.37 This
condition occurs in approximately 5% of women in the first year postpartum.37

Postpartum thyroiditis is often mild and transient. There is insufficient evidence to recommend screening all women
for postpartum thyroiditis. Women previously known to be TPO antibody positive should have a TSH performed at 3 and
6 months postpartum or as clinically indicated.33 The disorder may present as hyperthyroidism followed by hypothyroidism
and subsequent recovery of normal thyroid function. Some women may present with hypothyroidism without a hyperthyroid
interval and may remain hypothyroid.14 Up to 10–50% of the women who have had postpartum thyroiditis will go on to
develop permanent primary hypothyroidism after a postpartum thyroiditis episode.14

An annual TSH is recommended in patients with a history of postpartum thyroiditis.14 There is a significant risk for
recurrent postpartum thyroiditis in subsequent pregnancies.14

Controversies in Care
Controversies in Care: Universal Screening During Pregnancy
There is clear evidence that treating a pregnant woman known to be hypothyroid has important benefits.14 Treatment reduces
adverse pregnancy outcomes including preterm delivery or miscarriage38 and neuropsychological impairment of the offspring
is associated with hypothyroidism.34 At one time, studies suggested that failure to detect even subclinical hypothyroidism
might have similar consequences.34, 39 This led some groups to recommend that every woman be screened.40 Subsequent better
designed studies have not confirmed these concerns.41 In fact, harm could occur when pregnant women are overtreated.42 If
a woman has risk factors, TSH testing is specifically recommended in early pregnancy (see the section on Thyroid Disease in
Pregnancy).14 In a woman without symptoms and without risk factors, testing is discretionary.

Controversies in Care: Treatment of Pregnant Women with Subclinical Hypothyroidism

Although there is no strong evidence to support routinely measuring TPO antibodies in pregnant women, the American
Thyroid Association recommends that treatment may be initiated at lower TSH levels in women known to be TPO antibody
positive.14 If the TSH value is above 2.5 mU/L but within the reference interval, some practitioners would consider treating if
the TPO antibody is positive.

Resources
Practitioner Resources
• RACE: Rapid Access to Consultative Expertise Program – [Link]
A telephone consultation line for select specialty services for physicians, nurse practitioners and medical residents. If the
relevant specialty area is available through your local RACE line, please contact them first. Contact your local RACE line for the list
of available specialty areas. If your local RACE line does not cover the relevant specialty service or there is no local RACE line in your
area, or to access Provincial Services, please contact the Vancouver Coastal Health Region/Providence Health Care RACE line.
o Vancouver Coastal Health Region/Providence Health Care: [Link]
Available Monday to Friday, 8 am to 5 pm at 604-696-2131 (Vancouver area) or 1-877-696-2131 (toll free)
o Northern RACE: 1-877-605-7223 (toll free)
o Kootenay Boundary RACE: [Link]/kootenay-boundary/our-impact/team-based-care/race-line
1-844-365-7223 (toll free)

9 [Link]: Thyroid Function Testing in the Diagnosis and Monitoring of Thyroid Function Disorder (2018)
 o Fraser Valley RACE: [Link] (download at Apple and Android stores)
o South Island RACE: [Link]/ (download at Apple and Android stores) or see
[Link]/south-island/race
o Note that endocrinology on Vancouver Island is available through the Royal Jubilee Hospital/Victoria General Hospital
on call endocrinologist. The on call endocrinologist can be reached through [Link] or the Royal Jubilee
Hospital switchboard.
• Pathways – [Link]
An online resource that allows GPs and nurse practitioners and their office staff to quickly access current and accurate
referral information, including wait times and areas of expertise, for specialists and specialty clinics. In addition, Pathways
makes available hundreds of patient and physician resources that are categorized and searchable.

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Syntheses, formerly Systematic Evidence Reviews).
2. Hennessey JV, Klein I, Woeber KA, Cobin R, Garber JR. Aggressive case finding: a clinical strategy for the documentation of thyroid dysfunction. Ann Intern Med.
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3. Radetti G, Mazzanti L, Paganini C, Bernasconi S, Russo G, Rigon F, et al. Frequency, clinical and laboratory features of thyroiditis in girls with Turner’s syndrome.
The Italian Study Group for Turner’s Syndrome. Acta Paediatr. 1995 Aug;84(8):909–12.
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Preventive Health Care | The Red Brick: The Canadian Guide to Clinical Preventive Health Care (1994). p. 612–8.
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10. Dufour DR. Laboratory Tests of Thyroid Function: Uses and Limitations. Endocrinol Metab Clin North Am. 2007 Sep 1;36(3):579–94.
11. Persani L. Central Hypothyroidism: Pathogenic, Diagnostic, and Therapeutic Challenges. J Clin Endocrinol Metab. 2012 Sep 1;97(9):3068–78.
12. Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, et al. Guidelines for the Treatment of Hypothyroidism: Prepared by the American Thyroid Association
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Abbreviations
fT4 Free thyroxine
fT3 Free triiodothyronine
hCG human chorionic gonadotropin
TPO Thyroid peroxidase
TSH Thyroid stimulating hormone

Diagnostic Codes: 244 (Hypothyroidism), 242 (Hyperthyroidism)

Appendices
• Appendix 1: BC Laboratory Algorithm for Thyroid Tests

This guideline is based on scientific evidence current as of the effective date.

The guideline was developed by the Guidelines and Protocols Advisory Committee in collaboration with BC’s Agency for
Pathology and Laboratory Medicine and adopted by the Medical Services Commission.

THE GUIDELINES AND PROTOCOLS ADVISORY COMMITTEE

The principles of the Guidelines and Protocols Advisory Committee are to:
• encourage appropriate responses to common medical situations
• recommend actions that are sufficient and efficient, neither excessive nor deficient
• permit exceptions when justified by clinical circumstances
Contact Information:
Guidelines and Protocols Advisory Committee PO Box
9642 STN PROV GOVT
Victoria BC V8W 9P1
Email: [Link]@[Link]
Website: [Link]
Disclaimer
The Clinical Practice Guidelines (the “Guidelines”) have been developed by the Guidelines and Protocols Advisory Committee on behalf
of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem, and outline one or
more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for
the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of
clinical problem. We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions.
If you need medical advice, please contact a health care professional.

11 [Link]: Thyroid Function Testing in the Diagnosis and Monitoring of Thyroid Function Disorder (2018)
 Guidelines & Protocols Advisory Committee

Appendix 1: BC Laboratory Algorithm for Thyroid Tests

For a clinical algorithm, see guideline Figure 1: Clinical Algorithm for Thyroid Function Tests for Diagnosis and Monitoring
in Symptomatic Non-Pregnant Patients. Upper limit of normal = ULN.

Measure Report TSH,

*Specific Clinical Indications fT3 fT4 and fT3
- Suspicion of “pituitary” Normal
insufficiency ≥10 mU/L Measure
- “Thyrotoxicosis” fT4
- Patient age < 1 year at time Abnormal
Cancel fT3 Report TSH
of sample collection if ordered
- Previous TSH inconsistent and fT4
with patient presentation †
- Query analytical interference†
Measure Cancel fT3 Report TSH
†
Requires consultation with laboratory ULN-10 mU/L
fT4 if ordered and fT4
physician
High

Does a specific
TSH ordered Measure clinical No Cancel fT4 Report TSH
Normal and/or fT3
with TSH indication
fT4 and/or fT3 apply?*

Low
Yes

Measure Report
fT4 and fT3 TSH, fT4 and fT3

Does a specific
fT4 and/or fT3
clinical Measure Report
ordered without Yes
indication fT4 and/or fT3 fT4 and/or fT3
other thyroid test
apply?*

No

Cancel fT4
and fT3

[Link]: Thyroid Function Testing in the Diagnosis and Monitoring of Thyroid Function Disorder: Appendix 1: BC Laboratory Algorithm for Thyroid Tests (2018) 1